Wound Assessment: Part 1 Dot Weir, RN, CWON, CWS

Objectives To describe the rationale for accurate wound assessment and documentation. To recall the most common elements of a wound assessment. To identify important aspects of soft tissue, wound characteristics and underlying structures.

Wound Assessment Keypoints Foundation for developing goals and plan of care Ultimate driver of treatment decisions (wounds are dynamic / may change often) Evaluation of progress towards meeting goals of care (change from previous assessments) Important to have common language to facilitate consistent documentation van Rijswijk, L, Eisenberg, M. (2014) Wound assessment and documentation. In: Krasner, D.L. (Ed). Chronic Wound Care: The Essentials. Malvern, PA., HMP Communications

Wound Assessment Frequency and Documentation Complete assessment generally performed weekly - Evaluation of wound status : every dressing change - Observe for significant changes both positive and negative that may require treatment change Document per facility / agency protocol

Elements of the Wound Assessment Wound Etiology - Location Measurements - Surface area - Depth - Undermining, tracts & tunneling Exudate - Color - Character Tissue Type - Eschar - Slough - Granulation tissue - Epithelium Wound Edges & Surrounding Skin Structure - Bone - Tendon

Location Important to document correct anatomical location Left trochanter and left iliac crest versus left hip. Important to document correct anatomical location Use descriptors such as proximal/distal, anterior/posterior, superior/inferior with multiple wounds Left scapula versus left shoulder

Wound Etiology Diagnosis established by health care provider - Accurate diagnosis critical to guide treatment and goals of care (e.g. topical versus medical or combination of both) - Lower extremity wounds frequently have mixed etiology - Skin cancers may appear as small open area that fails to heal If wound is not progressing as expected with current management, look further/revisit treatment plan

Common Wound Etiologies Diabetic foot ulcer Surgical Peripheral Arterial Disease Misc. Atypical Wounds Skin Cancer Burn Trauma Pressure Ulcer Venous Ulcer

Wound Measurements Initial wound measurements critical as baseline to assess healing progress Length multiplied by the width will provide approximate (though usually overstated) surface area Length X Width X Depth can be calculated to provide approximate volume (using electronic medical records)

Wound Measurements – Length and Width Measure longest length of the wound and widest then perpendicular line to that for width

Wound Measurements – Depth Insert cotton end of sterile applicator into deepest part of wound at 90° angle to skin Grasp applicator at skin level, remove and measure using disposable measuring guide.

Undermining and Tracts Undermining is an area or space parallel to the skin Tracts (also called sinus tracts or tunneling) are narrow areas that extend beyond the depth or edge of the wound Important to assess, measure and document to guide treatment related to dressings and packing and to establish a baseline to assess healing

Undermining, Tracts and Depth Measurements: Document Using a “Clock” Method “Undermining 5 cm from 12 to 3 o’clock”

Drainage or Exudate: Amount Assessing amount is inexact unless dressings are weighed which is only done in clinical trials Assess to the extent possible knowing when the last dressing was changed Examples of estimating amount: Changed 1 week ago = Small Changed 2 days ago = Moderate Changed 1 hour ago = Large

Drainage or Exudate: Color Describe what you see Impacted by previous treatments, bacteria Common colors: Red, yellow, pink, tan, green

Drainage or Exudate: Character Common terms: - Serous: clear light yellow - Serosanguinous: clear pink/yellow - Sanguineous: red/bloody - Purulent: Usually white/tan, may be tinged with other colors, opaque, cloudy Use caution using the term purulent! Exudate may be byproduct of treatment: Autolysis, enzymatic debridement, cellular tissue products that have biodegraded, silver nitrate or other silver products

Exudate Character: Examples Serosanguinous Predominately serous Sanguineous

Exudate Character: Examples Tan Purulent Green Purulent Previous treatment residue; enzymatic ointment in use, expected outcome.

Exudate Character: Previous Treatment Residue

Tissue Types Eschar: Dark in color, may be dry or moist Slough: Necrotic tissue at some level of liquefying, may be dry or moist Granulation: Wound in process of healing, tissue pink or red, granular in appearance Clean non-granular: Wound bed pink or red but no evidence of healing Hyper-granulation tissue: Tissue growth above the level of the skin

Eschar Dry Eschar Soft Eschar © Dot Weir - Used with permission

Mixed Slough and Eschar Moist / Loose Dense / Adherent Mixed Slough and Eschar

Granulation Tissue Pink, Non-Granular Red, Granular

Hyper-granulation Tissue

Epithelium Migration of cells from the edge of the wound to resurface May be evident, or may be thin layer which gives surface of wound a matte appearance May originate in center of wound from structures such as hair follicles

Wound Edges and Surrounding Skin Assessing edges provides evidence of: Trauma: Callous, tearing Inadequate wound surface: Cells thickened at edge Epibole: Rolled edges, migration of cells down the wound edge closing them in

Callous/Rolled Edges

Epibole/Rolled Edges

Thickened

Surrounding Skin Identify Potential Issues Maceration Erythema (Infection?) Rash Reaction to treatment Fungal growth Excoriation Itching

Maceration

Erythema

Rash Reaction to Treatment Fungal Infection

Excoriation

Structures Recognizing visible or palpable deep structures such as bone, tendon or fascia is critical Potential for migrating infection or osteomyelitis Need to maintain moisture to prevent drying

Bone White, firm, shiny, either visually present in the wound, noted when cleansing or felt when gently probing deeper wound

Fascia Dense fibrous connective tissue that surrounds the muscles, bones, nerves and blood vessels

Tendon Cords of tough, fibrous connective tissue; glistening white in color

Summary Accurate assessment is foundation for developing plan and goals of care Accurate assessment guides wound treatment decisions Accurate assessment and documentation is foundation for evaluating progress towards meeting goals of care (change from previous assessments)

References Van Rijswijk L, Eisenberg M. Wound assessment and documentation. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, PA: HMP Communications; 2014:29-46. Baranoski S, Ayello E, Langemo D. Wound Assessment. In: Baranoski S, Ayello E. (eds) Wound Care Essentials, Practice Principles. Philadelphia, PA: Wolters Kluwer; 2016: 189-219. Livingston M, Wolvos T. Wound Assessment. In: Scottsdale Wound Management Guide. Malvern, PA: HMP Communications; 2015: 1-8.

Key Nursing Concepts Assessment Caring Communication Ethics Evidence-based practice Infection Infection Control Pain Patient Education Prevention Self Care Deficit Safety Tissue Integrity

Key Nursing Diagnoses Potential for Alteration in Skin Integrity Tissue Integrity Impaired Skin Integrity Impaired Tissue Integrity Oral Mucous Membranes, Altered Knowledge Deficit r/t Self Care Deficit r/t

Key Nursing Practice Issues Registered Nurses (RN) assess wounds; Licensed Practice Nurses monitor wounds per state nurse practice acts Physicians diagnose wound etiology; some Advance Practice Nurses diagnose wound etiology per state nurse practice acts Accurate wound assessment and documentation is foundation for evaluating attainment of progress towards goal of care

Websites for Further Information on Wounds - Association for the Advancement of Wound Care www.aawc1.org - Canadian Association for Wound Care www.cawc.net - National Pressure Ulcer Advisory Panel www.npuap.org - World Union of Wound Healing Societies www.wuwhs.org - Wound Ostomy Continence Nurses Society www.wocn.org

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